Kerndatensatz Senologie
0.9.0 - ci-build
Kerndatensatz Senologie - Local Development build (v0.9.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
{
"resourceType" : "Observation",
"id" : "Fall1-Verlauf-6Monate",
"meta" : {
"profile" : [
🔗 "https://www.senologie.org/fhir/StructureDefinition/senologie-follow-up"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Observation Fall1-Verlauf-6Monate</b></p><a name=\"Fall1-Verlauf-6Monate\"> </a><a name=\"hcFall1-Verlauf-6Monate\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-senologie-follow-up.html\">BIH Senologie Follow-Up (Verlaufsmeldung)</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 396432002}\">Status of regression of tumor (observable entity)</span></p><p><b>subject</b>: <a href=\"Patient-Fall1-Patient-Erika-Neumann.html\">Erika Neumann Female, DoB: 1966-03-12 ( http://fhir.bih-charite.de/sid/patient-id#SENO-2025-001)</a></p><p><b>focus</b>: <a href=\"Condition-Fall1-Diagnose-Mammakarzinom.html\">Condition Malignant neoplasm of breast</a></p><p><b>effective</b>: 2025-08-15</p><p><b>performer</b>: <a href=\"Organization-Brustzentrum-Charite.html\">Organization Brustzentrum Charité — Universitätsmedizin Berlin</a></p><p><b>value</b>: <span title=\"Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-gesamtbeurteilung K}\">keine Änderung (no change, NC) = stable disease</span></p><p><b>method</b>: <span title=\"Codes:{https://www.senologie.org/fhir/CodeSystem/cs-senologie-follow-up aktiv}\">Aktive Nachsorge</span></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 445200009}\">Status of residual neoplasm (observable entity)</span></p><p><b>value</b>: <span title=\"Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-primaertumor K}\">kein Tumor nachweisbar</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 399656008}\">Presence of metastatic neoplasm in regional lymph node (observable entity)</span></p><p><b>value</b>: <span title=\"Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-lymphknoten K}\">kein Lymphknotenbefall nachweisbar</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://snomed.info/sct 399608002}\">Status of distant metastasis (observable entity)</span></p><p><b>value</b>: <span title=\"Codes:{https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-fernmetastasen K}\">keine Fernmetastasen nachweisbar</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{https://www.senologie.org/fhir/CodeSystem/cs-senologie-follow-up zweittumor}\">Zweittumor</span></p><p><b>value</b>: <span title=\"Codes:{http://snomed.info/sct 373067005}\">No (qualifier value)</span></p></blockquote></div>"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "396432002",
"display" : "Status of regression of tumor (observable entity)"
}
]
},
"subject" : {
🔗 "reference" : "Patient/Fall1-Patient-Erika-Neumann"
},
"focus" : [
{
🔗 "reference" : "Condition/Fall1-Diagnose-Mammakarzinom"
}
],
"effectiveDateTime" : "2025-08-15",
"performer" : [
{
🔗 "reference" : "Organization/Brustzentrum-Charite"
}
],
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-gesamtbeurteilung",
"code" : "K",
"display" : "keine Änderung (no change, NC) = stable disease"
}
]
},
"method" : {
"coding" : [
{
"system" : "https://www.senologie.org/fhir/CodeSystem/cs-senologie-follow-up",
"code" : "aktiv",
"display" : "Aktive Nachsorge"
}
]
},
"component" : [
{
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "445200009",
"display" : "Status of residual neoplasm (observable entity)"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-primaertumor",
"code" : "K",
"display" : "kein Tumor nachweisbar"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "399656008",
"display" : "Presence of metastatic neoplasm in regional lymph node (observable entity)"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-lymphknoten",
"code" : "K",
"display" : "kein Lymphknotenbefall nachweisbar"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "399608002",
"display" : "Status of distant metastasis (observable entity)"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-verlauf-fernmetastasen",
"code" : "K",
"display" : "keine Fernmetastasen nachweisbar"
}
]
}
},
{
"code" : {
"coding" : [
{
"system" : "https://www.senologie.org/fhir/CodeSystem/cs-senologie-follow-up",
"code" : "zweittumor",
"display" : "Zweittumor"
}
]
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "373067005",
"display" : "No (qualifier value)"
}
]
}
}
]
}